Nokea
Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
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A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings does the nurse monitor?
- A. Serum creatinine.
- B. Spinal fluid analysis.
- C. Arterial blood gases.
- D. Serum osmolality.
Correct Answer: A
Rationale: Ceftriaxone can cause nephrotoxicity, so the nurse should monitor serum creatinine to assess kidney function. Spinal fluid analysis, arterial blood gases, and serum osmolality are not routinely monitored for ceftriaxone therapy.
A male client underwent a spinal fusion yesterday. Which of the following nursing assessments should alert the nurse to the development of a possible complication?
- A. Lateral rotation of the head and neck.
- B. Clear yellowish fluid on the dressing.
- C. No need to stand in order to void.
- D. Nonproductive cough.
Correct Answer: B
Rationale: Clear yellowish fluid suggests a cerebrospinal fluid leak, a serious complication requiring immediate attention.
The nurse is instructing the client about postsurgery activity following cataract surgery. What position should the nurse teach the client to use?
- A. Remain in a semi-Fowler's position.
- B. Position the feet higher than the body.
- C. Lie on the operative side.
- D. Place the head in a dependent position.
Correct Answer: A
Rationale: A semi-Fowler's position (head elevated 30-45 degrees) helps reduce intraocular pressure and swelling by promoting drainage and preventing fluid accumulation in the surgical eye.
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room?
- A. Transfer the client to a cart with manually suspended traction.
- B. Call the surgeon to request an order to temporarily remove the traction.
- C. Send the client on his bed with extra help to stabilize the traction.
- D. Remove the traction and send the client on a cart.
Correct Answer: C
Rationale: Transporting on the bed with extra help maintains traction stability, preventing fracture displacement.
A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs?
- A. Arms.
- B. Legs.
- C. Abdomen.
- D. Iliac crest.
Correct Answer: C
Rationale: The abdomen is the preferred insulin injection site for active individuals like joggers, as it provides consistent absorption and is less affected by exercise compared to the legs.